Diabetes Voice GLOBAL PERSPECTIVES ON DIABETES Volume 64 Issue 3 October 2017
WORLD DIABETES DAY 2017: WOMEN AND DIABETES Online registration closes November 13
Shape the future of diabetes www.idf.org/congress #IDF2017 CONTENTS
DIABETES VIEWS GLOBAL CAMPAIGN 4 Diabetes is a serious women’s health issue 23 IDF Congress 2017: Scientific Dr. Sania Nishtar Programme Manny Hernandez, Hak Chul Jang, Massimo NEWS IN BRIEF Massi Benedetti 6 IDF launches global survey on CVD awareness HEALTH DELIVERY 27 Lessons from WINGS 11 La Comunidad: community-based Belma Malanda diabetes prevention CLINICAL CARE
Diabetes in pregnancy: an opportunity 12 ADA and JDRF lead hurricane relief 30 for healthy change Jessica Lynn 13 Argentina: YLD member meets with Governor Online registration DIABETES IN SOCIETY 33 Women living with type 1 diabetes go Ecuador: Congress highlights 14 the distance Diabetes education key for Erin Spineto closes prevention–growth–empowerment
November 13 35 Type 1 diabetes and pregnancy SPECIAL FEATURES: WOMEN AND Ginger Vieira DIABETES 16 All women with diabetes deserve the right to a healthy future
17 Women with diabetes around the world
International Diabetes Federation © International Diabetes Federation, 2017 - All rights reserved. No part Promoting diabetes care, prevention and a cure worldwide of this publication may be reproduced or transmitted in any form or by Editor-in-Chief: Douglas Villarroel any means without the written prior permission of the International Editor: Elizabeth Snouffer Diabetes Federation (IDF). Requests to reproduce or translate IDF Editorial Coordinator: Lorenzo Piemonte publications should be addressed to [email protected]. Design and layout: Karen Joup The material in this document is for information purposes only. IDF All correspondence should be addressed to: makes no representation or warrantires about the accuracy and Elizabeth Snouffer, Editor reliability of any content in the document. Any opinions expressed are those of their authors, and do not necessarily represent the views of International Diabetes Federation IDF. IDF shall not be liable for any loss or damage in connection with Chaussée de La Hulpe 166, 1170 Brussels, Belgium your use of this document. Through this document, you may link to Tel: +32-2-538 55 11 | Fax: +32-2-538 51 14 third-party websites, which are not under IDF’s control. The inclusion Shape the future of diabetes [email protected] of such links does not imply a recommendation or endorsement by IDF of any material, information, products and services advertised on Diabetes Voice is available online at www.diabetesvoice.org third-party websites, and IDF disclaims any liability with regard to your Cover photo: iStock photo www.idf.org/congress #IDF2017 access of such linked websites and use of any products or services advertised there. While some information in Diabetes Voice is about medical issues, it is not medical advice and should not be construed as such. DIABETES VIEWS Diabetes is a serious women’s health issue Dr. Sania Nishtar
I recently had the privilege and the opportunity of age. Two of Rehmat’s sisters are on dialysis, due to end- travelling around the world as one of the three nominees stage diabetes-related renal disease, and already one sister for Director-General of the World Health Organization has undergone a heart bypass operation unsuccessfully. All (WHO). Wherever I went, in addition to presenting my sisters suffer from serious damage to their eyes—another candidature, I utilised the opportunity to visit hospitals, complication of diabetes. The burden of care for the entire hospices, primary healthcare centres and communities— extended family in emotional, physical and economic and everywhere, I found the footprint of diabetes terms is devastating. The opportunity cost weighs heavily disturbingly ubiquitous. The official figures are estimated in terms of the wellbeing and future outlook for their at 415 million adults currently living with diabetes and respective families. these estimates are projected to increase to 642 million by 2040. Approximately 199 million women live with The ravages of diabetes are not confined to the realm of diabetes which is projected to rise to 313 million by 2040.1 noncommunicable diseases (NCDs) alone. In technical I fear this may just be the tip of the iceberg. and public health parlance, diabetes is clubbed together with the other NCDs, and is as such siloed outside of the Girls and women with diabetes experience a range mainstream public health, which is still dominated by of challenges. Power dynamics, gender roles and infectious diseases and reproductive and maternal and socioeconomic inequalities influence vulnerability to child health (RMNCH). It is imperative that we recognise diabetes, such as by exposing women to poor diet and diabetes as an issue that straddles both RMNCH as well nutrition and physical inactivity disproportionately. as NCDs, as diabetes is a serious and neglected threat to These factors also affect women’s access to health services the health of mother and child. Two out of five women and health seeking behaviour, and amplify the impact of diabetes on women, particularly in developing countries.
Diabetes is one of the leading causes of cardiovascular disease (CVD), blindness, kidney failure and lower-limb It is imperative that we amputation. In pregnancy, poorly controlled diabetes increases the risk of maternal and fetal complications. recognise diabetes as an issue Diabetes is the ninth leading cause of death in women that straddles both RMNCH as globally, and causes 2.1 million deaths per year. Women well as NCDs with type 2 diabetes are 10 times more likely to have heart disease and have significantly increased risk of depression in comparison to men. Globally, there are more deaths with diabetes are in reproductive age and half of all cases attributable to diabetes in women than men. of hyperglycaemia in pregnancy occur in women under the age of 30, accounting for over 60 million women These are not mere statistics, but facts which incur heavy worldwide. One in seven births is affected by gestational physical and emotional and economic toll on families. The diabetes (GDM). IDF estimates that 20.9 million or a suffering of four sisters in my country, Pakistan, epitomizes staggering 16.2% of live births in 2015 had some form of the problem millions of women face worldwide. At 44 hyperglycaemia in pregnancy. Women with diabetes have years, Rehmat is the youngest of four sisters—all of more difficulty conceiving and may have poor pregnancy whom are obese. Recently Rehmat was hospitalised for a outcomes. Many women with GDM experience pregnancy diabetic foot amputation, a common and tragic outcome related complications including high blood pressure, large of uncontrolled diabetes, which will place great difficulties birth weight babies and obstructed labour. A significant and challenges for her ahead, being so scarred at a young
4 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 DIABETES VIEWS
number of women with GDM also go on to develop type 2 Antenatal care visits during pregnancy must be optimised diabetes resulting in further healthcare complications and for health promotion in young women and early detection costs. of diabetes and GDM.
Most alarming is that the vast majority of cases of We can no longer afford to treat diabetes and NCDs as the hyperglycaemia in pregnancy have been found to be blind spot of our policies. There must be a conscious effort in low- and middle-income countries, where access to to drive change. Constituents of IDF can be the drivers maternal care is limited. GDM can also leave its mark on of that change. They must marshal the much-needed women for life, as approximately half of women with a momentum now, and as a matter of right, not choice, not history of GDM go on to develop type 2 diabetes within options. five to ten years of delivery. Women with type 1 diabetes have an increased risk of early miscarriage or having a baby with malformations, in any case.
There is, however, a silver lining to this problem. We know that the majority of cases of type 2 diabetes could be prevented through the adoption of a healthy lifestyle. Approximately, seventy percent of premature deaths among adults are largely due to behaviour initiated during adolescence which is where the potential of lifestyle modification is greatest. This is where the role of women and girls is critically important as they are the key agents in the adoption of healthy lifestyles to improve the health and wellbeing of future generations. As gatekeepers of household nutrition and lifestyle habits they have the potential to drive prevention from the household and beyond.
For all these reasons, I would like to lend my voice of support to IDF’s message on World Diabetes Day to its constituencies—a network of thousands of foundations and societies all over the world. This network has an enormous influence to cascade IDF messages in their countries to governments, policymakers, civil society, the scientific community and people in general to catalyse a whole of societies approach to tackling this challenge.
At a broader public health and health systems level, Dr. Sania Nishtar of Pakistan is a former federal minister and diabetes prevention and management, along with extensive prominent global health leader with extensive experience measures aimed at NCD prevention and control need in public healthcare. She was among the three candidates to be mainstreamed in country planning with adequate nominated for the post of Director-General of the World Health attention to the specific needs and priorities of women Organization (WHO) in 2017. with diabetes. Women and girls should be empowered with access to knowledge and resources to strengthen their capacity to prevent type 2 diabetes in their families and better safeguard their own health. In addition, type 2 diabetes prevention strategies must focus on maternal 1. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. health and nutrition and other health behaviours before Brussels, Belgium: International Diabetes Federation, 2015. and during pregnancy, as well as infant and child nutrition.
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 5 NEWS IN BRIEF IDF launches global survey on CVD awareness
IDF, in collaboration with Novo Nordisk, has million people worldwide died from noncommunicable launched Taking Diabetes to Heart, a multi- diseases (NCDs) of which 17.5 million were related to country study on cardiovascular disease CVD. In 2015, approximately 5.0 million people were (CVD) awareness in people with type 2 diabetes. The estimated to have died from diabetes, and a majority of results of the survey will support the development these were the result of cardiovascular complications. of tools, educational resources and policies designed to facilitate implementation of recommendations IDF released the global report on Diabetes and included in the IDF’s global report on Diabetes Cardiovascular Disease in 2016 and recommendations and Cardiovascular Disease. A primary goal of the for people with or at risk for diabetes included: recommendations is to reduce the burden of CVD among people living with or at risk for diabetes. • Public health measures to promote healthy diets • Increased physical activity Insights gathered from the global survey will enable the development of awareness and education • Smoking cessation campaigns among key stakeholders including people • Implementation by national governments of NCD living with diabetes and healthcare professionals. monitoring systems • Improving access to essential diabetes and CVD People with diabetes are at increased risk of medicines. CVD. Existing studies, mainly from developed countries, suggest that CVDs account for over one- An online questionnaire has been developed in multiple third of all deaths among people with diabetes. languages. The preliminary results of the study will be As the number of people with diabetes continues to presented at the IDF Congress 2017 in Abu Dhabi in increase, the outlook for CVD becomes even more December 2017. alarming. In 2012, it was estimated that over 37.9 Stress hormones and metabolism altered by air pollution
A recent study conducted in Shanghai, China suggests period during which the filters were removed, researchers that exposure to air pollution is associated with heart did another nine-day test: the students in the original disease, stroke, diabetes and early mortality. The study functioning-filter group got non-working filters, and those investigated changes in serum metabolites in response to in the original nonfunctioning-filter group got filters that the reduction of particulate matter (PM) exposure among worked. At the end of each nine-day period, the researchers healthy college students. tested levels of a wide range of small molecules in students’ blood and urine as indication of their exposure to PM. Working or non-working air purifiers were placed in each Metabolomics analysis showed that high exposure to PM student’s dorm and left in place for nine days. After a 12-day may induce metabolic alterations such as increases in
6 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 NEWS IN
hormones including cortisol, cortisone, and epinephrine. Differences were observed in blood glucose, amino acids, fatty acids and lipids. Researchers found significantly higher blood pressure, hormones, insulin resistance and biomarkers of oxidative stress and inflammation among individuals exposed to higher PMs with aerodynamic diameters ≤2.5 μm.
The research adds new evidence on how exposure to air pollution may lead to a higher risk of NCDs, including cardiovascular disease and diabetes.
Huichu L, Jing C, Renjie C, et al. Particulate matter exposure and stress hormone levels a randomized, double-blind, crossover trial of air purification. Circulation 2017; 136: 618-627. https://www.ncbi.nlm.nih.gov/pubmed/28808144 High prevalence of diabetes, prediabetes in China
A large, nationally representative survey in 2013 of adults in China finds that the estimated overall prevalence of diabetes was about 11 percent and that of prediabetes was nearly 36 percent, according to a study published by JAMA.
Previous studies have shown increasing prevalence of diabetes in China, which now has the world’s largest diabetes epidemic. To provide more recent estimates of the prevalence of diabetes and prediabetes, researchers analysed data from a nationally representative survey conducted in 2013 in mainland China, which included
170,287 participants. Fasting plasma glucose and HbA1c • Tibetan and Muslim Chinese had significantly lower levels were measured for all participants. Diabetes and prevalence of diabetes than Han participants (14.7 prediabetes were defined according to the 2010 American percent for Han, 4.3 percent for Tibetan, and 10.6 Diabetes Association criteria. percent for Muslim).
Findings included: With approximately 1.09 billion adults in total in mainland China, it is projected that 388.1 million Chinese adults • The estimated prevalence of total diagnosed and (200.4 million men and 187.7 million women) may have undiagnosed diabetes was 10.9 percent; that of diagnosed had prediabetes in 2013. diabetes, 4 percent; and that of prediabetes, 35.7 percent.
• Among persons with diabetes, 36.5 percent were Wang L, Gao P, Zhang M, et al. Prevalence and ethnic pattern aware of their diagnosis and 32.2 percent were treated; of diabetes and prediabetes in china in 2013.JAMA. 2017; 49.2 percent of patients treated had adequate glycemic 317(24):2515-2523. control. http://jamanetwork.com/journals/jama/article-abstract/2633917
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 7 NEWS IN BRIEF Study finds diabetes and heart disease linked by genes
In a large analysis of genetic data, published in Nature the genetic link between the diseases appears to work Genetics, researchers from the Perelman School of in one direction, so that risk genes for type 2 diabetes Medicine at the University of Pennsylvania (USA) have are much more likely to be associated with higher studied what causes type 2 diabetes and secondly, clarified CHD risk than the other way around. Additionally, how type 2 diabetes and coronary heart disease (CHD)– there could be some pathways where pharmacological two diseases that are the leading cause of global morbidity lowering of one disease increases the risk of the other. and mortality–are linked. Researchers also found that diabetes-linked gene Examining genome sequence information for more than variants tend to differ in their apparent effects on CHD 250,000 people, the researchers first uncovered 16 new risk, depending on their mechanisms. Variants that diabetes genetic risk factors, and one new CHD genetic increase the chance of obesity or high blood pressure, risk factor providing novel insights about the mechanisms for example, appear to boost CHD risk more strongly of the two diseases. They then showed that most of the than variants that alter insulin or glucose levels. sites on the genome known to be associated with higher diabetes risk are also associated with higher CHD risk. For eight of these sites, the researchers identified a specific gene Zhao W, Rasheed A, Tikkanen E, et al. Identification of new variant that influences risk for both diseases. The shared susceptibility loci for type 2 diabetes and shared etiological genetic risk factors affect biological pathways including pathways with coronary heart disease. Nature Genetics 2017; immunity, cell proliferation, and heart development. doi:10.1038/ng.3943. http://www.nature.com/ng/journal/vaop/ncurrent/full/ng.3943. html?foxtrotcallback=true The findings add to the basic scientific understanding of both these major diseases and point to potential targets for future drugs. The researchers found evidence that
Risk of type 2 diabetes associated with artificially sweetened beverages
Artificially sweetened beverages are associated with an The study included 64,850 women who enrolled in the increased risk of developing diabetes, according to a re- Women’s Health Initiative between 1993 and 1998. Par- cent study. However, substituting a serving of either an ticipants in the study completed lifestyle questionnaires artificially sweetened beverage (ASB) or sugar-sweete- that were used to measure ASB, SSB and water intake. ned beverage (SSB) with water might reduce the risk. Study participants self-reported their diabetes status.
8 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 NEWS IN BRIEF NEWS IN BRIEF
During the mean 8.4 years of follow-up, 4675 women had developed diabetes. Consumption of ASBs and SSBs was associated with an increased risk of developing diabetes. However, the researchers only found an increased risk of diabetes associated with ASB consumption for partici- pants with obesity during subgroup analyses.
While substituting SSBs with an equal amount of ASBs did not significantly reduce the risk of developing diabe- tes, substituting either beverage with water was found to reduce the risk. Replacing a serving of ASB with water re- duced the risk of diabetes by 5%, and replacing a serving of SSB reduced the risk by 10%.
Researchers concluded that while ASBs were associated with a 21% increased risk of developing type 2 diabetes approximately half the magnitude of SSBs (43% increased Huang M, Quddus A, Stinson L, et al. Artificially sweetened risk)—replacing ASBs and SSBs with water could poten- beverages, sugar-sweetened beverages, plain water, and incident tially reduce the risk. The researchers also added that cau- diabetes mellitus in postmenopausal women: the prospective Women’s Health Initiative observational study. Am J Clin Nutr. tion should be taken in interpreting their results as causal 2017;106: 614-22. because both residual confounding and reverse causation could explain results.
Type 2 diabetes risk four times higher in women with PCOS
Women who have polycystic ovary syndrome (PCOS) the Nation Patient register for each woman with PCOS. have a higher risk of developing type 2 diabetes (T2D) and are diagnosed at an earlier age with the condition, Researchers found that women with PCOS were four according to a new study published in the Endocrine times more likely to develop T2D compared to their Society’s Journal of Clinical Endocrinology & Metabolism. counterparts who did not have the disorder. The average The study is the first to show a connection between T2D age for women with PCOS who received a diagnosis of development and PCOS. T2D was 31 years. The average age for women without PCOS and diagnosed with T2D was 35 years. To determine the risk of T2D development in women with PCOS, researchers studied two populations with PCOS: ll Body mass index, insulin and glucose levels, and pre-menopausal Danish women with a diagnosis of PCOS triglycerides were positively associated with development in the National Patient Register (18,477 women) and a of T2D, whereas a higher number of births were local sub-group of 1,162 women with PCOS who were negatively associated with the development of T2D. examined at Odense University Hospital in Denmark. The The study’s authors note that BMI and fasting blood local participants were tested for insulin and glucose levels, glucose levels are the best predictors of the development cholesterol, triglycerides and testosterone levels. Women of T2D in patients with PCOS. Increasing age, however, with PCOS were compared with age-matched females who should not be included in future guidelines as a risk factor did not have the disorder, nor a previous diagnosis of T2D. because most cases of diabetes in this study were found Three women without PCOS were randomly selected from
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 9 NEWS IN BRIEF before the age of 40. The authors add that further research is needed to evaluate the effect of oral contraceptives and Rubin KH, Glintborg D, Nybo M, et al. Development and risk factors number of births for the risk of T2D development in PCOS. of type 2 diabetes in a nation-wide population of women with polycystic ovary syndrome. JCEM 2017 https://academic.oup.com/ “The increased risk of developing T2D in PCOS is an jcem/article-lookup/doi/10.1210/jc.2017-01354, ahead of print. important finding,” said one of the study’s authors, Dorte Glintborg. “Diabetes may develop at a young age and screening for diabetes is important, especially in women who are obese and have PCOS.” Gaining weight between pregnancies may increase risk for GDM
Results from a study conducted in Norway found that the about 36 percent of the women gained weight, and 17 risk of gestational diabetes (GDM) in second pregnancy percent lost it; weight remained stable for the remaining rises significantly with increasing weight gain between 47 percent. During the second pregnancy, 439 women pregnancies, and more strongly among women who had developed GDM. Those who had gained weight between a BMI below 25 (kilo/meters squared) in first pregnancy. pregnancies were more likely to have developed GDM These study findings may suggest weight change as a than were women whose weight had stayed steady. metabolic mechanism behind the increased risk of GDM, and therefore may point to a need to include weight change Along with improved GDM screening, researchers as an independent factor for screening GDM in clinical emphasize the need to target healthy weight from guidelines. The study also found that decreasing BMI by >2 preconception through the postpartum period. units from first to second pregnancy had a preventive effect on GDM in overweight and obese women.
In the observational cohort, 24,198 mothers who were Sorbye LM, Skjaerven R, Klungsoyr K, et al. Gestational diabetes mellitus and interpregnancy weight change: A population- based pregnant twice in about an eight-year span but did not cohort study. PLoS Med 2017; 14(8): e1002367. https://doi. develop GDM during their first pregnancy were included org/10.1371/journal.pmed.1002367 in data from the Medical Birth Registry of Norway (2006–2014). Between their first and second pregnancies,
10 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 NEWS IN BRIEF “La Comunidad”: community-based diabetes prevention
Type 2 diabetes mellitus (T2D) disproportionately affects not meet the study inclusion criteria. This finding is of Hispanic Americans; they are almost twice as likely to concern as it suggests that Latino women are less healthy have T2D compared to non-Hispanic whites and 1.5 and at higher risk for T2D than Latino men. Additionally, times as likely to die from the disease. Several studies in the HELP PD study, the average age was 57.9 years while have demonstrated the potential for the prevention of in “La Comunidad” the age was 41.5 years, suggesting that T2D through lifestyle change, yet these interventions Latinos are at risk for developing diabetes earlier in life. have not been disseminated effectively into Latino communities. Given the higher risk for T2D in Latino For more information: communities there is a great need for cost-effective and https://clinicaltrials.gov/ct2/show/NCT01831921 sustainable interventions for diabetes prevention and health promotion.
The Latinos Combatiendo La Diabetes (La Comunidad) study was adapted to model the Healthy Living Partnerships to Prevent Diabetes (HELP PD), a translation of the Diabetes Prevention Program that yielded nearly identical results (Vitolins, Blackwell et al).
“La Comunidad” was designed to translate the community-based HELP PD intervention for delivery by Latino Health Workers (LHAs). Two hundred and twenty-five overweight/obese (BMI 25-45 kg/m2) Latino adults at risk for T2D (HbA1c 5.7-6.4%) were randomized to a lifestyle intervention or to a usual care condition. The goal of the intervention was to achieve 5-7% weight loss through increased physical activity and decreased caloric intake. Intervention materials from the highly successful HELP PD program were translated into Spanish and adapted for use in the Latino community, including a DVD series to aid in fidelity of the intervention delivery.
Intervention participants attended weekly group meetings led by LHAs for six months, followed by meetings every other month for 18 months. Usual care participants received counseling with a registered dietitian and monthly newsletters. The primary outcome was change in HbA1c. Secondary outcomes included markers of metabolic syndrome were collected every 6 months. Participants in “La Comunidad” had a mean age at baseline of 41.5 years, 191 (84.9%) were female, and the mean BMI at baseline was 32.8 kg/m2. During the screening and enrollment process, fewer men qualified to participate as they did
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 11 NEWS IN BRIEF ADA and JDRF lead hurricane relief
JDRF and the American Diabetes Association (ADA) with diabetes whatever they need to stay safe in the announced they will provide emergency support to the management of their disease while they work to get the diabetes community affected by Hurricane Irma just as rest of their lives in order after this terrible storm,” said they did for Huricane Harvey, and they will do so with the Derek Rapp, JDRF President and CEO. “People with type support of two additional organizations. 1 diabetes simply can’t live without insulin and other supplies. We’re grateful for the partnership with these The American Association of Diabetes Educators (AADE) diabetes care organizations, especially their efforts to help and the Endocrine Society are joining ADA and JDRF in this emergency.” as the coalition prepares to provide emergency help to those that will be affected by Hurricane Irma. Other A special webpage with information and resources — coalition members include the American Association of diabetes.org/hurricanerelief — is available for those with Clinical Endocrinologists (AACE), Insulin For Life and diabetes, caregivers, and on-site responders and care Research!America. professionals facing the hurricane. It includes shelter locations; how to advocate for themselves or a loved JDRF and the coalition marshaled their resources in a new one with diabetes; how to help someone with diabetes hurricane relief effort launched last month to help those and signs of a diabetes emergency; and additional impacted by Hurricane Harvey. The organizations provi- resources from partners on how to access supplies and/or ded information, medical supplies and support to people medication. Information will be updated regularly. with diabetes in Texas (USA) to help them manage their diabetes during the crisis. They teamed up with Insulin During emergency crises such as this, it is critical for For Life, an organization that delivers insulin and testing people with diabetes to have access to the medications supplies to people in need. Together, the organizations and testing supplies needed to maintain proper delivered more than 7,000 pounds of diabetes supplies, blood glucose control, and to prevent serious sudden including syringes, pen needles, alcohol pads, blood complications such as hypoglycaemia or hyperglycemia. glucose meters, glucose test strips, lancets, and insulin — in both analogue and human insulins and vial and pen forms. More information. “Right now, it’s critical that we help provide people
12 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 NEWSNEWS IN IN BRIEF Argentina: YLD member meets with Governor
From left to right: Gladys González, former National Deputy and current candidate for National Senator; Estefania Malassisi, IDF Young Leader in Diabetes; Maria Eugenia Vidal, Governor of the Province of Buenos Aires; Liliana Tieri, Director and Founder of CUI.D.AR; and Esteban Bullrich, Minister of Education of the Nation.
On July 14, 2017, the Governor of the Province of Buenos Estefanía discussed diabetes care with Governor Vidal Aires, Maria Eugenia Vidal, accompanied by the Minister and showed her the medicines and supplies that people of Education, met Estefania Malassisi, an IDF Young with diabetes require including a blood glucose meter, test Leader in Diabetes (YLD) to learn more about the work strips, insulin and a glucagon kit. The Governor was very of Asociación para el Cuidado de la Diabetes in Argentina interested as Estefania explained the importance of access to CUI.D.AR and what it means to live with type 1 diabetes. these essential life-saving supplies for people with diabetes. Governor Vidal was very keen to learn what the needs and issues are for people who live with diabetes in the Estefania Malassisi has lived with type 1 diabetes since age Province. two. Currently she studies medicine and dreams of being a pediatrician and diabetes specialist. For two years, CUI.D.AR has tried to arrange a meeting with Governor Vidal in order to discuss the needs of At CUI.D.AR, we are proud of Estefania’s achievements. people with diabetes in the Buenos Aires Province. This The work of IDF’s YLD program is critical to achieve all changed with the work of Estefania who independently success in diabetes advocacy worldwide. We hope that wrote the Governor to tell her story and how she works her success can become an inspiration for other young to advance diabetes as a part of YLD and CUI.D.AR. people with diabetes who are fighting to improve care, Governor Vidal was so taken with Estefania’s letters that treatment and rights for people with diabetes. she prioritized a meeting with the young woman.
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 13 NEWS IN BRIEF Ecuador: Congress highlights Diabetes education
Participants of the third International Congress of Education in Diabetes (June, 2017).
How do we define diabetes education? This was precisely development of serious complications. Comprehensive the topic of the Third International Congress of Education care is based on the following elements: medical care, in Diabetes (June 2017, Guayaquil, Ecuador) organized nutritional counseling, physical activity plan, family by the Casa de la Diabetes Foundation which also support and structured diabetes education. commemorated the organisation’s 15th year anniversary. The congress was attended by experts from Spain, Mexico, The following are excerpts from a few of the significant Venezuela, Colombia, Costa Rica and Ecuador. All discussions that were held at the June 2017 Congress: participants supported an important component of the Congress agenda: the need to provide not only medical Dr. Rosa María Aguilar, a Mexican researcher, teacher and advice to people with diabetes, but also provide self- expert on diabetes discussed how diabetes education is management education which gives a greater opportunity often a specialty that just doesn’t exist in many countries of for growth and empowerment. the world, but can be provided by healthcare professionals. It is her belief that this vision of healthcare provider Lifestyle changes can make all the difference for diabetes as educator is critical for a healthy community where prevention and families of people living with or at risk diabetes poses such a great risk. Structured educational of type 2 diabetes must be integrated into community interventions adapted to the needs of each person will initiatives. It should be noted that the lack of proper help win the war on diabetes. information, poor adherence to treatment or lifestyle changes and absence of a support network often lead to the “With a clear, simple and sincere language we can reach our
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patients, it is necessary to take advantage of those spaces healthy diet, without unnecessary food deprivation or offered by the media, communities and neighborhoods excess, for lack of knowledge. to socialize information and continue to educate about diabetes, so we could boost efforts and save many lives,” In sum, let us look at diabetes as an opportunity to rethink said Dr. Aguilar. a new way of life where together healthcare providers can help patients not only with scientific knowledge, but also Ana Fernanda Sánchez (Ecuador), a diabetes educator by giving more time and effort. Diabetes is an opportunity and clinical psychologist and Adriana Gómez (Colombia), to work and to walk together as a team for better health! a nutrition expert, believe a diabetes educator is responsible for demonstrating the impact of education For more information on Casa de la Diabetes Foundation: on the lifestyle generating behavioral changes for better diabetes self-care. Sánchez explained how individualized • Internet: http://casadeladiabetes.org.ec/ education is necessary from the very first consultation • Facebook: https://www.facebook.com/ and follow-up. This dynamic process, where delivery CasaDeDiabetes/ of varied diabetes information is offered, demands an • Twitter: @CasaDeDiabetes. interactive and therapeutic relationship between the educator and the person with diabetes. Negotiating with a patient for lifestyle changes can be very important for progress. Individualized education protects a patient’s privacy, seeks to generate empathy and as a result, gains a patient’s confidence. Regarding group therapies, Gómez emphasized that diabetes educational sessions should be provided in small groups and include families and/or patient support networks.
Dietician and diabetes educator, Adriana Herrera (Costa Rica), believes diabetes education is an ongoing process, since each educational program must consider that the needs of patients are changing and renewed according to the requirements of each individual. Evaluating aspects biomedical parameters (such as HbA1c, and blood pressure values) as well as psychosocial aspects (such as quality of life, well-being and self-care) need to be reviewed with positive reinforcements set against achievements and improvements of previously set objectives.
Nutrition and diabetes experts, Ana Gladys Arauz (Costa Rica) and Adriana Herrera (Costa Rica) discussed how food is a fundamental pillar for the prevention and treatment of diabetes. One challenge is how knowledge in this area is continually changing, not just recommendations and nutritional guidelines but also in teaching methodologies. Documenting patient education activities allows progress of each patient to be seen and gives an opportunity to evaluate obstacles that have been presented in fulfilling patient objectives. Availability to the entire healthcare team assists when assessing achievements. Carbohydrate counting, glucose monitoring, and other skills are necessary to support a
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 15 SPECIAL FEATURE: WOMEN AND DIABETES All women with diabetes deserve the right to a healthy future
The theme of this year’s World Diabetes Day (WDD) The program will be launched at an IDF stakeholder event campaign is Women and Diabetes, with the slogan in Brussels on November 14, The event will also serve to Our Right to a Healthy Future. Many activities are planned promote the release of the 8th edition of the IDF Diabetes this November 14, 2017 to bring greater awareness to Atlas, providing the latest data on the prevalence of women at risk for or living with diabetes around the world. diabetes worldwide.
Led by the International Diabetes Federation (IDF), the World Diabetes Day 2017 will serve as a vehicle to deliver campaign is promoting the importance of affordable and key advocacy information and request recognition and equitable access for all women at risk for or living with renewal of the 22 action based commitments for the diabetes for access to the essential diabetes medicines response to noncommunicable diseases (NCDs) that and technologies, self-management education and governments agreed to in 2012. The aims and objectives information they require to achieve optimal diabetes of WDD 2017 support WHO voluntary targets on 0% outcomes and strengthen their capacity to prevent type 2 increase in diabetes prevalence and 80% access to essential diabetes. diabetes care by 2025 as well as the Global Monitoring Framework on NCDs and the target under Goal 3 of the There are currently over 199 million women living with Sustainable Development Goals, which aim to reduce diabetes and this total is projected to increase to 313 one-third premature mortality from non-communicable million by 2040. Diabetes is the ninth leading cause of diseases through prevention and treatment by 2030. A death in women globally, causing 2.1 million deaths each letter will be sent to all IDF Members who will be requested year. As a result of socioeconomic conditions, women and to tailor it with information from their own country, girls with diabetes experience barriers in accessing cost- deliver the document to their national governments and effective diabetes prevention, early detection, diagnosis, take an active role in obtaining government recognition treatment and care, particularly in developing countries. and renewal of their commitments by signing the letter.
In view of the particular burden of the disease and its As is the custom, the global diabetes community will be impact on women’s lives, IDF will mark World Diabetes marking World Diabetes Day 2017 with a wide range of Day 2017 with the launch of a new program that aims to awareness and advocacy activities in November, in the initiate a wide range of actions in support of women living more than 160 countries represented by IDF. A snapshot with diabetes in Middle East and North Africa (MENA), of these activities can be viewed on the WDD events map North America and Caribbean (NAC), South America and – www.idf.org/wdd-events. Central America (SACA), sub-Saharan Africa (SA) and South-East Asia (SEA). IDF actions will focus on capacity Visit www.worlddiabetesday.org for more information and building for health professionals including train-the- resources about the World Diabetes Day 2017 campaign. trainer sessions, face-to-face workshops, online refresher CME sessions, and the development and dissemination of information and advocacy resources. 16 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 SPECIAL FEATURE: WOMEN AND DIABETES Women with diabetes around the world
To support IDF’s World Diabetes Day 2017 theme of “Women and diabetes: Our right to a healthy future”, Diabetes Voice reached out to a variety of public or privately supported initiatives focused on improving the lives of women with diabetes around the world. In Singapore, we learn about the Ministry of Health’s determination to reduce the risk of diabetes for their population with an emphasis on women and their families, and in Italy, the Donna (Woman) Study Group explores potential gender differences in the quality of care in Italy, with special emphasis on cardiovascular risk factor targets and current treatments. In the US, we are introduced to a research team helping Latina women overcome barriers to diabetes self- management and prevention strategies, and we meet DiabetesSisters, a US nonprofit organisation who with online and in-person outreach provide support and education without judgment. Finally, in Saudi Arabia, we learn that women there are overcoming cultural barriers to access healthier lifestyles.
Singapore: Empowering women in the ‘war on diabetes’
Participants of “Healthy Kitchen, Healthy Women.”
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 17 SPECIAL FEATURE: WOMEN AND DIABETES
Diabetes is a global health concern. In Singapore, 1 in diabetes. Initiatives are being developed to anchor care 9 residents aged 18 to 69 have diabetes: of these, 1 in 3 in the community to facilitate holistic management and persons are undiagnosed. Among those diagnosed, 1 continuity of care for women post-delivery. Upstream, in 3 have poor blood sugar control. Recognising this, our preventive efforts include tackling the modifiable risk Singapore’s Health Ministry declared ‘war on diabetes’ factors through various strategies. HPB in collaboration for a whole-of-nation effort to better prevent, screen and with KK Women’s and Children’s Hospital, developed a control diabetes. national mobile application allowing pregnant women to track their body mass index, blood pressure and blood Apart from managing their own risk factors for diabetes sugar levels, and offered personalised health content. and other chronic diseases, women play an important role in their families as they can influence food and lifestyle Currently, screening for diabetes is recommended for choices at home. Singapore’s Health Promotion Board Singaporeans 40 years and older. Later this year, we will (HPB) works with grassroots and women’s groups to launch a diabetes risk assessment (DRA) tool to assess the raise women’s awareness of diabetes. For example, HPB risk of undiagnosed diabetes in Singaporeans between 18 worked with the People’s Association Women’s Executive to 39 years old. This can help nudge those identified “at- members to publish a collection of healthy recipes entitled risk” to attend screenings, and adopt habits to prevent “Healthy Kitchen, Healthy Women” and community talks diabetes. We want all younger women to use the DRA on diabetes prevention and management were held to tool to assess their risk, and encourage their peers to promote the initiative. follow suit.
HPB’s efforts also extend to identifying persons with We hope that this year’s World Diabetes Day theme – increased risk of developing diabetes later in life, and “Women and Diabetes” – will inspire women to take up exploring ways to reduce this risk. One important group a pivotal role in our ‘war on diabetes’ and help our loved is women with gestational diabetes (GDM) who also have ones lead healthier, happier lives. a higher risk of pregnancy complications. Close to 1 in 5 pregnant women in Singapore have GDM. GDM also Contributed by Dr Amy Khor, Senior Minister of State places babies at higher risk for obesity and type 2 diabetes. (Health and Environment & Water Resources), Singapore.
In Singapore, routine GDM screening is offered to all pregnant women at public healthcare institutions. This is a 1. National Health Survey 2010. 2. Poor control is defined as Hba ≥8% shift from previous guidelines where only pregnant women 1c at high risk were screened. Subsidies are also available to support eligible women in their regular screening for
Italy: Gender differences in treating type 2 diabetes
The impact of diabetes on cardiovascular risk is Italian national healthcare system, allows the monitoring particularly evident in women, who experience more of a large set of process and outcome indicators and the major cardiovascular events, especially myocardial use of specific classes of drugs. The “Donna (Woman)” infarction, and higher mortality rate, even during pre- Study Group analyzed the AMD Annals data to explore menopause. In Italy, a continuous improvement effort potential gender differences in the quality of care in Italy, by a network of diabetes clinics has been implemented with particular regard to the achievement of cardiovascular since 2006 under the aegis of the L’Associazione Medici risk factor targets and current treatments. Diabetologi (AMD), called the AMD Annals Initiative. Overall, 415,294 patients from 236 diabetes outpatient The AMD initiative, which includes approximately one- centers were evaluated, of whom 188,125 (45.3%) third of all diabetes outpatient clinics operating within the were women. We found that gender disparities are less
18 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 SPECIAL FEATURE: WOMEN AND DIABETES
AMD Donna Group. pronounced in Italy than in other countries, but they have HbA1c levels >8.0% (64mmol/mol), mainly in more still exist, despite equal access to specialist care and elderly patients. universal coverage of healthcare costs. The achievement of targets for the major cardiovascular risk factors is Since men and women with type 2 diabetes receive the systematically unfavorable to women with diabetes, who same “quantity and quality of care for their diabetes”, are more obese, often have a worse control of diabetes our data suggest that other biological, genetic and/ and worse lipid profile, and a higher frequency of reduced or behavioral factors may underline these differences, glomerular filtration rate, with a lower prevalence of and gender-specific studies are needed to explore these microalbuminuria. potential areas of intervention.
In the world, women with diabetes are systematically Contributors: Valeria Manicardi, Maria Chiara Rossi, under-treated with drugs for cardiovascular risk factors, Giuseppina Russo, Patrizia Li Volsi, Nicoletta Musacchio, such as ASA, ACE-I, β-blockers, statins, and hypoglycemic Domenico Mannino on behalf of the “Donna” Study agents, and this may explain the failure to achieve Group” of AMD (Diabetologists’ Medical Association). recommended targets. On the contrary, the Italian data do not confirm the trend by showing that there are no gender differences in the use of drugs: women and men are similarly treated with statins (40% both), but the difference in reaching the LDL target is still evident in all age-strata; women are more frequently treated with two or more antihypertensive drugs and the results in hypertension control are the same; women are more frequently treated with insulin or insulin and oral hypoglycemic drugs than men, but women were 11% more likely than men to
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 19 SPECIAL FEATURE: WOMEN AND DIABETES
USA: Improving outcomes for Latina women
La Comunidad participants.
Although research studies have demonstrated that problematic. The lack of affordable, healthy food choices weight-loss through increased exercise and reduced that are both appealing and culturally appropriate can also calorie intake can help prevent or delay the development make improving their diets difficult. Finally, some Latina of type 2 diabetes and recent efforts on the national level women face challenges in fostering and maintaining have been aimed at diabetes prevention, these programs support for weight-loss and healthy habits in their own have yet to be effectively disseminated in Hispanic/Latino households. The La Comunidad study could provide communities. Statistics from the American Diabetes important insight into overcoming these barriers and Association suggest that the rates of diabetes are higher in improving health outcomes in Latina women. Hispanic/Latina women than in the general population in the United States. Hispanic/Latina women tend to develop Contributed by Mara Vitolins, lead researcher for The diabetes younger in the lifespan than non-Hispanics and Latinos Combatiendo La Diabetes (La Comunidad) study. are two to three times more likely to develop the disease. By Dr. Vitolins is Professor, Epidemiology & Prevention age 70, more than 50 percent of these women have diabetes Office of Women in Medicine and Science Center on compared to around 10 percent for non-Hispanic whites. Diabetes, Obesity, and Metabolism at Wake Forest School Researchers at Wake Forest School of Medicine developed of Medicine, North Carolina (USA). a group-based weight-loss intervention for diabetes prevention and have now adapted it for delivery in the local Latino community. The weight-loss intervention being tested is designed to be delivered in a community setting by a peer lay health advisor with support and training from healthcare professionals.
Beginning in 2014, 225 Hispanic/Latino participants have enrolled in the Latinos Combating Diabetes (La Comunidad) study. Of these, 191 are female, presenting the study team with a unique opportunity to examine the challenges faced by Latina women as they strive to make healthier lifestyle choices. Many of these women work more than one job or work longer hours, making it difficult to find time for exercise each day. Similarly, childcare, transportation, and rotating work schedules make attendance at the weekly group meetings
20 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 SPECIAL FEATURE: WOMEN AND DIABETES
USA: DiabetesSisters offers support to all women with diabetes
DiabetesSisters (USA)
Founded in 2008, DiabetesSisters is a non-profit the message of education, support, and empowerment to organization dedicated to improving the health and women with diabetes around the country. As of June 2017, quality of life of women with or at risk of developing the organization had over 13,000 registered members and diabetes. The organization serves the community both nearly 10,000 social media followers. The website also online and in-person, providing support and education in receives half a million visitors annually. a safe, non-judgment zone. Online, DiabetesSisters offers innovative, user-friendly Addressing the needs of women living with diabetes web-based programs to address the various ways women candidly, DiabetesSisters has tackled sensitive subjects prefer to connect with others and receive diabetes such as pregnancy, parenting with diabetes, menopause education. For women who prefer to learn through quiet and eating disorders, discussing and learning about each observation, DiabetesSisters provides articles (blogs) from topic and providing professional and peer support along actual women living with type 1 and type 2 diabetes. In the way. Filling this gap has been instrumental in their between visits with her healthcare team, a member can success, with women returning to DiabetesSisters events engage with healthcare professionals via From the Experts and discussing their progress. Another issue that has been Columns or download educational materials from an prevalent has been stigma and isolation in living with educational library. Registered members receive a monthly diabetes. Our programming emphasizes that no woman e-newsletter which features tips and resources for living should walk the path of diabetes alone. Because our better with diabetes. Additionally, DiabetesSisters offers a community is inclusive, women with all kinds of diabetes free Life Class Webinar Series, with a 30-minute focus on can share their successes, triumphs, struggles and fears, a specific diabetes-related topic. and have other Sisters provide their own experiences in the same realm. We have recently started to speak about Additionally, since 2009, DiabetesSisters has offered in- issues on the rising cost of medications and the fear in person monthly PODS (Part of DiabetesSisters) Meetups losing access to diabetes treatment. in various locations throughout the US, as well as a Virtual Meetup for those who cannot meet in person. Various The organization works with national government times a year, we host a Global PODS Meetup, which has agencies, national corporations, private practitioners, included women from Brazil, United Kingdom, India, women’s organizations, and diabetes organizations to carry and Ghana. In 2015, the organization received funding
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 21 SPECIAL FEATURE: WOMEN AND DIABETES to offer a Leadership Institute open to PODS Leaders, where we come together to enhance skills in recruitment and facilitation, as well as receive more education in diabetes. We also offer a Weekend for Women Conference, which has become a signature event for DiabetesSisters, drawing attendees from all over the US with all types of diabetes of varying ages. Recently, DiabetesSisters launched a Minority Initiative Program, designed to reach underserved populations and provide more resources and everyday ways to improve life with diabetes. This program has offered programs such as cooking demonstrations, exercise suggestions, and resource sharing.
For more information on DiabetesSisters, please visit www.diabetessisters.org Contributed by Anna Norton, CEO of DiabetesSisters.
Saudi Arabia: New opportunity for women and girls to access exercise
In Saudi Arabia, women cannot exercise with men and there are no public sports facilities for women, but things are changing. For the first time, women in Saudi Arabia are being encouraged to exercise in public gyms due to the efforts of a prominent Saudi princess, Princess Reema Bint Badar, who became head of a new Department of Women’s Affairs at the General Authority of Sports last year. This has been widely seen as signalling the potential for greater female access to sports in the Saudi Arabia, a country where women’s participation in sports has been relatively rare.
Following the appointment of Princess Reema in November 2016, the General Authority for Sports and the prestigious Princess Nora University in Riyadh, the largest women’s university, signed a memorandum of cooperation for the promotion of sports facilities with a view to the promotion of healthy lifestyles. Further plans in relation to women’s sports include:
• the licensing for the first time of women’s gyms; and
• modifying outdoor areas to allow women to work out without being seen by men.
Allowing gyms for women and access to a healthier lifestyle could make a huge difference for the overall health of Saudi women. Around 44 percent of women are classified as obese in Saudi Arabia, and the country has some of the world’s highest rates of obesity and diabetes. Saudi Arabia is currently following a modernisation program called Saudi Vision 2030 where one of the aims When unveiling the licensing in March of 2017, Princess is to increase the scale of community participation in Reema said the change is about “opening the doors for sports from 13 per cent to 40 per cent by 2030. our girls to live a healthy lifestyle.” The Princess also said the Islamic Kingdom planned for every district From: Developments in Saudi Sports following Saudi and neighborhood to have a gym, and while swimming, Vision 2030: accessed on the Internet Sept 6, 2017; running and bodybuilding will be allowed, a blanket ban will remain for competitive sports like tennis, football, volleyball and basketball.
22 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 IDF Congress 2017: Scientific Programme
The global diabetes community will unite on 4-8 December for the IDF 2017 Congress in Abu Dhabi, United Arab Emirates. The 2017 Congress will include more than 200 expert speakers, 230 national diabetes associations from 170 countries and high level participation from the Health Authority Abu Dhabi (HAAD) and other health organisations. IDF’s scientific programme will take place over four days with the aim of delivering worldwide diabetes expertise through varied and innovative program stream sessions.
For 2017, IDF has nine streams covering all areas of the field of diabetes. Below, Manny Hernandez, Stream Lead for Living with Diabetes; Hak Chul Jang, Stream Lead for Diabetes in Women and Children; and Massimo Massi Benedetti, Stream Lead for Diabetes in Society and Culture provide the opportunity for us to learn more about their respective programs and what they have planned for the 2017 IDF Congress.
Living with Diabetes
Manny Hernandez
As we approach our global gathering in Abu Dhabi this December, I’m glad to reconnect with fellow people with diabetes (PWD) and other friends and colleagues from around the world.
Since 2016, I’ve been working alongside an incredible group of advocates to bring to life the 2017 World Diabetes Congress Living with Diabetes (LWD) stream. Deputy Lead Renza Scibilia (Australia), Kelly Close (USA), Mary Shi (China), and Hakeem Adejumo (Nigeria) are to be thanked for the extraordinary program congress attendees will have an opportunity to participate in and learn from. In the context of this Diabetes Voice issue, dedicated to “Woman and Diabetes”, I feel honored that more than two thirds of the 34 speakers we will hear from in our stream in Abu Dhabi are women: mothers, daughters, sisters… all touched by diabetes.
A cornerstone Living with Diabetes (LWD) session will be the Wim Wientjens Memorial Symposium: “Hypoglycaemia and time-in-zone”, to be chaired by Kelly In the past five years, the #WeAreNotWaiting movement Close, with Daniela Rojas (Costa Rica), Simon Heller has impacted the lives of thousands of people with type (UK), and Bart Van der Schueren (Belgium). Dr Wientjens 1 diabetes (T1D) around the world. OpenAPS (Open lived with diabetes from 1951 until his passing in 2016. Artificial Pancreas System) gives anyone with compatible He was a staunch champion for people with diabetes, and medical devices who is willing to build their own system in his last years focused his advocacy on hypoglycaemia. the tools to have basic overnight closed loop APS Presentations about the personal impact of severe low BG, technology. Renza Scibilia will moderate a debate that impaired hypoglycaemia unawareness, and time-in-zone will likely be standing room-only: Dana Lewis (creator as a new endpoint beyond HbA1c will allow us to honor of the OpenAPS) and Annie Astle (a UK mother of a Wim’s legacy. child with T1D) will argue for the rationale built into
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#WeAreNotWaiting versus “why are we waiting” regarding diabetes technology. Manny Hernandez (@askmanny) is the Living with Diabe- tes, Stream Lead. From shame and blame to living with diabetes “in the He was born in Venezuela and has been living with type 1 closet”—the stigma of diabetes is very real and keeps diabetes since 2002. Manny co-founded TuDiabetes.org and people with diabetes from realizing their full potential. I EsTuDiabetes.org in 2007 and is currently Senior Vice Presi- dent of Member Experience at Livongo Health. will have the honor of chairing a symposium about the stigma surrounding diabetes. Rivers Solomon (UK) and Mohammad AlBahar (Kuwait) will share the European and Middle-Eastern perspectives, and Sama Ajmal (Pakistan) will focus on the topic from the point of view of young women in the developing world.
The LWD stream will also touch on emotional and mental health aspects of life with diabetes and the importance of peer-to-peer support; dive into how language matters when speaking to and about people with diabetes; and explore diabetes tools and apps… all from the perspective of people with diabetes.
I look forward to seeing you in Abu Dhabi. If you see me roaming around the Convention Center, don’t hesitate to say “HOLA!”
Diabetes in Women and Children
Hak Chul Jang
Hyperglycaemia in pregnancy includes both gestational diabetes mellitus (GDM) and diabetes mellitus in pregnancy. IDF estimates that 20.9 million or 16.2% of live births to women had some form of hyperglycaemia in pregnancy worldwide in 2015. GDM is one of the most prevalent metabolic disorders during pregnancy. Women with GDM have an increased risk of adverse pregnancy outcomes and both mothers and their children are at increased risk of developing type 2 diabetes. In addition, women with past GDM also have higher prevalence of metabolic syndrome and cardiovascular diseases in later life.
The Diabetes in Women and Children (DWC) Stream for the IDF Congress 2017 in Abu Dhabi will provide programs covering several important issues including detection and diagnosis of GDM, update of diabetic pregnancy management, prevention of GDM in women with high risk, prevention of type 2 diabetes and /or
24 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 THE GLOBAL CAMPAIGN
cardiometabolic syndrome in women with past GDM, diabetic pregnancy” along with recent updates of medical and long-term complications of offspring of women nutritional therapy and pharmacological treatment with diabetes. One highlight will be the IDF Congress during pregnancy. 2017 Award Lecture given by Professor Boyd Metzger, the primary investigator of the HAPO study. He will The management of children and adolescents with type discuss the challenges in the diagnosis of GDM. Further 1 or type 2 diabetes will be presented and discussed in recognizing the emerging controversy of diagnosis of an open session of the DWC stream. The International GDM, the IDF–International Federation of Gynecology Society for Pediatric and Adolescent Diabetes (ISPAD) and Obstetrics (FIGO) joint symposium and special lecture entitled, Perils of the postpubertal period, will session for the diagnosis and management of GDM in be given by Joseph Wolfsdorf, MD, BCh, Director of the low-resourced settings will be held. Diabetes Program at Boston Children’s Hospital (USA).
Our program offers sessions covering reproductive issues for women living with diabetes including discussions Hak Chul Jang is a Professor of the Department of Internal on contraception, polycystic ovary syndrome (PCOS) Medicine, Seoul National University College of Medicine and menopause. As medical services using ICT-devices and Stream Lead for Diabetes in Women and Children. have been developed to improve diabetes management, we will explore the “Role of ICT and mHealthcare in
Diabetes in Society and Culture Massimo Massi Benedetti
The Diabetes in Society and Culture (DSC) Stream is designed to stimulate the IDF community to consider the impact on diabetes of environmental and cultural factors in a wide advanced perspective through sessions dealing with
• Primary and secondary prevention.
• Scientific methodologies for real life evidence.
• Relationship between diabetes and beliefs.
• Partnership with service organisations.
• Role of public and private partnership.
• Integration of people with diabetes in the society.
• Relationship between migrants and host societies.
Primary and secondary prevention are most frequently approached with traditional clinical trials which less) ample cohorts. Their value is undeniable to prove evaluate the impact of a restricted, selected number the concept of prevention. However, an unpredictable of environmental and behavioural factors in (more or number of factors which vary and have a different
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impact in diverse environments, societies and cultures esteem and resilience. has a relevant effect on the implementation of real life preventive programs at the population level. The topic of Migrants is of high relevance in our world Appropriate and robust scientific methodologies need today. However, the DSC program is subdivided into to be adopted and possibly developed to design, monitor one, the burning condition of “refugees” which is being and provide evidence of the outcomes of population considered in a specific stream and two, the condition of based interventions. These issues will be dealt with in “legal” migrants who find difficulties in long-term full Session 1: The role of society in primary integration into the new country of residence. This is prevention of diabetes: Health in all policies; of particular relevance for people with diabetes as they Session 2: The role of society in secondary prevention might experience difficulties with language, nutritional of diabetes: cultural and socio-economic factors; and in behaviours, beliefs and more which may interfere with Session 3: Real life evidence and value based diabetes care. diabetes management and control.
The DSC session on Diabetes and beliefs highlights Massimo Massi Benedetti is President and Scientific examples on how beliefs, and not only religious ones, Director, Hub for International Health ReSearch HIRS, IDF can influence the lives of people with diabetes. Much has Senior Programme Advisor and Stream Lead for Diabetes in already been said about diabetes and Ramadan, while little Society and Culture. attention is paid to food and beliefs generally especially regarding the growing diffused attitudes towards nutrition. Additionally, the role of traditional healers, evaluated with appropriate scientific methodologies, is proven to represent a valuable resource in environments where modern healthcare has objective difficulties to penetrate.
The open forum on Service organizations and Foundations should motivate the IDF community to establish more structured partnership with independent humanitarian agencies not only to increase the availability of economic resources but also, and possibly more importantly, to take advantage of their cultural background and networks to increase awareness on diabetes in various societies throughout the world.
The debate on the Public-private partnership should represent an opportunity for IDF to re-evaluate its relationships with public or private partners having in mind old and new prejudices. Caveats and opportunities are to be evaluated objectively to select the right partner for any specific initiative by taking advantage of newly prevailing doctrines in economy within the frame of the sustainable development concept
The Symposium on Integration of people with diabetes in the society deals with an issue that is deeply relevant in the daily life of people with diabetes. Administrative and at workplace discrimination is well known, however more subtle forms of discrimination undermine the daily life of people with diabetes with different expressions and perceptions in different cultures generating reduced self-
26 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 HEALTH DELIVERY Lessons from WINGS Belma Malanda
Notwithstanding several decades of research, there are several constraints to gestational diabetes (GDM) care, from screening to postpartum follow-up. Awareness and knowledge about GDM is poor even among healthcare professionals (HCPs). Furthermore, lack of standardized protocols in screening and management, and lack of coordination among HCPs involved in providing care for GDM often results in less than optimal care and poor follow‑up during pregnancy and after delivery. The postpartum period provides an opportunity for lifestyle intervention to prevent future risk of diabetes
To address these challenges and critical gaps in effective care for GDM, WINGS (Women In India with GDM Strategy), a three and a half year-long project, was conducted by IDF from 2012 to 2015 in Chennai, Tamil Nadu, India, with the aim of developing a model of care that is suitable for women with GDM in low‑ and middle‑income countries. It was carried out in two phases.
In Phase 1, a situational analysis was conducted to understand the practice patterns of healthcare professionals and determine the best screening criteria which was achieved through a pilot study. In Phase 2, the project aimed to develop a standardized approach to GDM care that was evidence‑based, feasible, and acceptable in resource‑constrained settings. The project also aimed to evaluate the effectiveness of this new model of care (MOC).
WINGS take-home messages After implementation of the WINGS MOC, women with follow-up check for diabetes after the delivery. WINGS GDM were found to have pregnancy outcomes similar to demonstrated that through an intensive and continued pregnant women without GDM, i.e, the general population effort, universal post-partum follow up is achievable, of Tamil Nadu. Most importantly, WINGS saw ninety- which creates a significant opportunity for prevention of six percent of women return for follow-up after delivery type 2 diabetes. which is a new record of sorts in India where post-partum follow-up rates are usually between ten to twenty percent. WINGS demonstrates that following a structured model of care, pregnancy outcomes in women with GDM can be At the six weeks follow-up screening, four percent of improved to the level seen in non-diabetic women. This women had developed type 2 diabetes. This percentage multi‑level strategy helps to approach GDM at not only at likely reflects pre-existing diabetes in these women the individual level but also at the family and community and further emphasizes the need for an immediate levels providing a holistic approach to overcome barriers to care. The framework of the GDM model of care1
The WINGS pilot phase was made local by using materials global scientific audience with a variety of initiatives in Tamil and Hindi languages as well as English. Aligning and programs. with the new WHO definition on GDM, WINGS was a joint community and health facility-based intervention for the • At the individual and family level, WINGS aimed management of GDM. The WINGS MOC is suitable for to build the awareness and education on GDM integration into existing maternal and child health systems, through one‑on‑one counseling, educational strengthening capacity to address GDM and improving programs, and various educational materials. health outcomes of women with GDM and their newborns. An educational booklet on GDM entitled “Having a baby?” was developed for pregnant mothers. The WINGS model approach to care for GDM was The booklet uses simple and easy to understand developed targeting the individual (pregnant women), language to educate women on defining GDM, how their families, the health facility, community, and the it develops, who is at risk, and instructions related to
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 27 HEALTH DELIVERY
self-managing the condition, such as blood glucose scientific publications, the model was disseminated testing, healthy eating, safe exercise and an area for and made available to the global community. diary keeping. Click here for more information. Study HCP participants found that WINGS provides a • At the health facility level, capacity building comprehensive package of tools for every level of care was done by training HCPs in identifying, focusing on diagnosis, management, and follow‑up of treating, and managing GDM. A training women with GDM who were followed prospectively curriculum was developed for this purpose . throughout their pregnancy. The educational booklet, discussed above, offers guidance on self‑management of • At the larger community level, especially the remote GDM including sample meal plans and physical activity and the rural regions which have limited access and tips. Medical nutrition therapy (MNT) was the first line availability to GDM care, community health workers of treatment given to women with GDM and women (CHW) were trained with basic awareness and were advised to undergo fasting blood glucose and information about GDM. Community‑based activities postprandial blood glucose testing every fortnight— were conducted as part of the WINGS outreach insulin was indicated when the target blood glucose levels program with the help of experts in the field of nutrition. were not achieved with MNT. Women were evaluated for Pregnant women were invited to attend the program pregnancy outcomes and postpartum glucose tolerance and were educated about proper nutrition and physical status. activity through cooking demonstrations and lively interactive sessions. Link to CHW training manual. The issue: GDM in low- and middle- 2 • Reaching out to a broader global audience was income countries always a part of the WINGS objective with the idea GDM contributes to about ninety percent of diabetes that the implementation of the model in India would complicating pregnancy. help to provide insights and recommendations for improved care of women diagnosed with GDM in Prevalence of GDM has dramatically increased in the other low‑resource settings. Through peer-reviewed past 20 years among various ethnic groups. IDF estimates
28 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 HEALTH DELIVERY
that as of 2015, 16.2% of women with live births had some form of hyperglycemia in pregnancy, 85% of which were due to GDM. There is a notable difference in the prevalence of GDM, with the IDF South-East Asia Region (SEA) having the highest prevalence (87.6%) of all the low‑and middle‑income countries where access to care is often limited. Asian women are more prone to develop GDM than European women and Indian women have an 11‑fold increased risk of developing glucose intolerance in pregnancy compared to Caucasian women. Studies done in the 1980’s estimated the prevalence of GDM in India at two percent which substantially increased to 16.55% in 2000.
GDM imposes risks for both mother and fetus, and some of these risks continue throughout the life of mother and child. Immediate maternal complications include preeclampsia, need for cesarean sections, and poly/oligohydramnios. Complications in the baby include hyperinsulinemia, macrosomia, shoulder dystocia, neonatal hypoglycemia, and respiratory distress syndrome. Women with GDM are at an increased risk of GDM in future pregnancies and they are also at a higher risk of developing type 2 diabetes in the future. GDM also increases the risk of obesity and glucose intolerance in the offspring. GDM is an important public health issue that has major repercussions for both mother and offspring. Detection of GDM provides a window of opportunity to intervene and reduce adverse perinatal outcomes.3
For more information on IDF work on GDM. 3. Kapur A. Pregnancy: A window of opportunity for improving WINGS was developed and supported through a current and future health. Int J Gynaecol Obstet 2011; 115 Suppl 1: S50‑1. partnership between IDF, the Madras Diabetes Research Foundation (MDRF) in Chennai, India, and the Abbott Fund, the philanthropic foundation of the global healthcare company Abbott. The study was approved by the Institutional Ethics Committee of the MDRF. Permission was also obtained from the Directorate of Public Health and the Ministry of Health, Government of Tamil Nadu, to conduct the study in the primary health centers.
Belma Malanda, MD, MPH is Senior Programmes Manager for IDF.
1. Kayal A, Mohan V, Malanda B, et al. Women in India with Gestational Diabetes Mellitus Strategy (WINGS): methodology and development of model of care for gestational diabetes mellitus (WINGS 4). Indian J Endocr Metab 2016; 20:707-15.
2. International Diabetes Federation. IDF Diabetes Atlas. 7th ed. Brussels, Belgium: International Diabetes Federation; 2015.
Volume 64 - Issue 3 - October 2017 Diabetes Voice Online 29 CLINICAL CARE Diabetes in pregnancy: an opportunity for healthy change Jessica Lynn
In July, the Centers for Disease Control (CDC) published updated statistics on diabetes in the United States. Nearly half the US population has diabetes or its precursor, pre- diabetes.1 On one hand, these numbers are staggering. On the other, there’s no disease with such opportunity for prevention and even reversal. When I was growing up with type 1 diabetes (T1D), my father often reminded me how fortunate I am to have a manageable disease. He told me I could live a long and even healthier life as a result of having T1D. “It’s not a death sentence. It’s an opportunity!” he’d say.
I realize this is not a typical viewpoint. Barriers to managing a chronic disease are many and multifaceted. Taking advantage of an opportunity like this requires desire, consciousness and a confluence of positive factors, including mental and physical health, access to healthcare, education, financial tools and community support.
In addition to having diabetes and the privilege of being a mother of two, I am a nurse midwife and perinatal diabetes educator. I have had the great honour of delivering babies and caring for women with diabetes in the US, Jamaica and Guatemala. Today, I am part of a dedicated diabetes-in- pregnancy practice at NYC Health + Hospitals, Woodhull in Brooklyn (New York, US) with a team of high-risk doctors, nurses and dietitians. We work in a diverse and under-served population where rates of diabetes and its complications are even higher than average in the US. We recognize the need to provide more comprehensive Jessica Lynn screening and support as our population has been deeply affected by racial and socioeconomic health disparities. of their lives? Working with a population of pregnant women who have diabetes, I am inspired to see their remarkable potential I developed and continue to update diabetes in pregnancy as change agents. They have the lowest no-show rate. guidelines for the New York City public hospital system, They readily make healthier food choices and decide to but guidelines are not enough. Diabetes in pregnancy exercise. They consistently drop their HbA1c throughout deserves a conversation, a sharing of ideas for how to pregnancy. Their health habits routinely influence their make change happen. In addition to talking with patients families. Women are lifestyle guides for their children, and other healthcare providers, I often speak to obstetrics partners, parents, churches and schools. Observing this departments to encourage more comprehensive diabetes made me wonder: what if we could help women sustain prevention and management. Here are some highlights the healthy changes made during pregnancy for the rest from my presentations:
30 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 CLINICAL CARE
Pregnant women with the clinical team of Woodhull Hospital’s Diabetes in Pregnancy Practice
All health care providers need diabetes education neonatal complications and childhood disease including Diabetes is no longer a disease for endocrinologists obesity, T2D and non-alcoholic fatty liver disease. When alone, nor solely primary care providers. Diabetes is I tell a woman she has diabetes in pregnancy, she is often present in every medical specialty and at home for people frightened, disappointed, and confused. I reassure her it’s without any medical care. In obstetrics, we are often the not the diabetes diagnosis but high blood glucose that first healthcare access point for women. This makes us can cause harm to her and her baby. I always let her know primary care providers. To help create positive change that our medical team will help her learn how to manage in the diabetes epidemic, I encourage all healthcare blood glucose and reduce her risks of complications. providers to borrow some wisdom from a diabetologist. Collaborate across disciplines Suspect hyperglycaemia The American Congress of Obstetricians and Knowing that hyperglycaemia affects almost half our Gynecologists (ACOG) recently made sweeping population, we added HbA1C to our initial labs for all changes in their GDM guidelines: recommending more pregnant women with or without known diabetes. We comprehensive screening, expanding the time frame for have been able to put individual hyperglycaemia on postpartum glucose testing, and reconsidering the role of the map, screen women earlier for gestational diabetes insulin in pregnancy as opposed to oral hypoglycemics.2 mellitus (GDM) and more closely follow changes in Throughout the guidelines, ACOG referenced the glycaemia throughout pregnancy. We actively find position of the American Diabetes Association. undiagnosed type 2 diabetes (T2D), as well as identify This is an example of sharing research and clinical and discuss pre-diabetes within a receptive population. experience to improve outcomes. Good news for all!
High blood glucose is the culprit, not diabetes Women need individualized and culturally specific care Hyperglycaemia (undiagnosed or unmanaged) causes First line therapy for diabetes is lifestyle change, and miscarriage, excessive fetal growth, birth trauma, lifestyle is affected by cultural, socioeconomic and family increased caesarean section rates, and even fetal death. factors. It’s important to get to know your patient. Ask her Hyperglycaemia in pregnancy also contributes to what happens in a typical day. Is her schedule determined
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by her children’s activities? Does she work at night? Does Eliminating liquid carbohydrate can have a powerful effect she eat pizza and soda and or tacos and rice? Consider on health, changing the course of diabetes. Recently, a helping her tailor her life, instead of overhauling it. This woman in our practice with no known history of diabetes leads to a higher likelihood of success. We have a Yemeni had an HbA1c of 6.7% at her initial prenatal visit. She was population at my hospital and I noticed many women drinking 4 glasses of juice a day, but otherwise had a healthy have high blood glucose following their afternoon meal. I diet of moderate carbohydrate, no processed food, lots of learned they were eating asida, essentially a cooked wheat vegetables and proteins. Still, I thought she would need flour sometimes with butter or honey and often eaten insulin therapy. Fortunately, she was willing to completely alone. Once I knew this, I was able to suggest workable stop drinking juice. I had her monitor blood glucose and options: smaller portions, limiting the honey, and return in 5 days. To my surprise, her blood glucose was going for a walk after the meal. Talking about culturally 100% within our pregnancy target. She proceeded to drop important factors like asida and fasting during Ramadan her HbA1c to 5.9% in the second trimester and 5.2% by the have been trust building. The ultimate result: improved third trimester having made just that one change in her diet. blood glucose that’s sustainable in pregnancy and beyond. Believe in the ripple effect Every visit is a preconception visit Think of women as central to the health of their families With or without diabetes, almost half of pregnancies and communities. Talk about reducing or eliminating in the United States are unintended. Unplanned juice and soda intake. Encourage more physical activity, pregnancy is associated with poor outcomes, more stress reduction and adequate sleep. Women can and will so for women with diabetes. Healthcare providers alter the lifestyles of their children and beyond. They are should have preconception discussions with women central to the powerful ripple effect for change we need to of childbearing age. One Key Question® can be a see in diabetes. useful tool. Ask women at every visit ‘Would you like to become pregnant in the next year?’ If the answer is Be inspired. Be positive. Diabetes is an opportunity for no, offer contraception. If yes, provide preconception health! care. For women with diabetes, this starts with HbA1c <6%. In our busy practice, we encourage this approach. Jessica Lynn, MSN, CNM, CDE is a nurse midwife and perinatal diabetes educator in Brooklyn. She has lived Discuss goals with women passionately with T1D for more than 40 years, and devotes I’ve seen first-hand that pregnant women are interested her career to diabetes care for women. in health and extremely goal oriented. Discuss targets for blood glucose, HbA1c, and weight at every visit. I often give women their HbA history in writing so they can be 1. Centers for Disease Control and Prevention. National 1c Diabetes Statistics Report, 2017. National Center for involved and proud when they meet their goals. Pregnant Chronic Disease Prevention and Health Promotion, women with diabetes can and do reach those goals, Division of Diabetes Translation. July 17, 2017. Accessed more often when discussed with a healthcare provider. via Internet: https://www.cdc.gov/diabetes/pdfs/data/ statistics/national-diabetes-statistics-report.pdf GDM is a form of prediabetes 2. The American College of Obstetricians and Gynecologists. Gestational diabetes does not disappear at birth. This Practice Bulletin: Gestational Diabetes Mellitus. July 2017. myth of its disappearance is pervasive and potentially Accessed via Internet: https://www.acog.org/Womens- injurious. At the time of their initial postpartum glucose Health/Gestational-Diabetes testing, nearly half of women diagnosed with GDM 3. Bellanca HK, Hunter MS. “One key question” Screening have either impaired fasting glucose, impaired glucose women for pregnancy intentions as a critical reproductive health strategy. Oregon Foundation for Reproductive tolerance, or overt diabetes. I tell every woman I meet Health. Accessed via Internet: https://www.arhp.org/ in our practice, “You have gestational diabetes which uploaddocs/RH13_Presentation_One_Question.pdf often leads to type 2 diabetes. However, your healthy changes in diet, weight loss, exercise, and breastfeeding can help prevent or delay diabetes in your future.”
Small changes are important changes
32 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 DIABETES IN SOCIETY Women living with type 1 diabetes go the distance Erin Spineto
Erin and Erika prepare for (stand up) paddle boarding.
Each year, I lead a team of people with type 1 diabetes This year, as part of the One Drop Caicos adventure, my (T1D) on what is often considered the adventure of a trek with Erika Young and Kati Long included 50 miles lifetime. In the summer of 2017, I wrapped up another on paddle boards, 20 miles hiking and swimming, and one of my Sea Peptide adventures, this time in the another 50 miles on bikes for a total of 120 miles from beautiful waters of Turks & Caicos. On my adventures, South Caicos to North Caicos. The goal? To get a group of the following philosophies are key for success: people living with T1D together to push beyond what we think we are capable of achieving. Living with diabetes day • Every person with diabetes can be happy. in, day out can get tough, and having or making adventures • Every person with diabetes needs others to remind us that we are more than just our diabetes. We are commiserate with, to plan with, and to adventure stronger than our highest highs and lowest lows. We all with. need a little reminding every now and then! • Your big adventure may not be the same as my big adventure — but whatever your BIG is, you We started training in January, 2017. I put together a can find a way to make it safe with diabetes. training program for Erika, Kati & myself at the start of
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When I finish and succeed on an adventure, I am always motivated to take good care of my diabetes and after returning from the Caribbean, I am once again back home with a renewed passion for taking amazing care of my diabetes.
While I set out on these adventures always with a mile- marker in mind (this time, it was 120), the end-goal isn’t about hitting that magic number any more than taking care of diabetes is about always catching a blood sugar unicorn (100 mg/dL). Instead, it’s all about doing the best we can, together, and pushing ourselves to do better than yesterday. And our trio learned to do just that.
Erin Spineto was diagnosed with diabetes in 1996. When the year and for the next six months leading up to the trip, she ran out of motivation after fighting hard for twelve we trained each day, keeping each other accountable and years, she turned to adventure to provide the motivation updated on our progress even though we do not live in she sought starting with a 100-mile solo sail down the proximity to each other. Florida Keys. You can read more about her adventures on her blog: SeaPeptide.com. Erin currently lives in San Die- go, California, USA. When One Drop Caicos finally began, our trio was ready for action. Our team was set; we had all our diabetes supplies carefully packed, meals and snacks planned out for our days, and specially-designed rigs that I made to carry backpacks (which included essential diabetes supplies). We towed our rigs behind us in the water as we swam from cay to cay.
When you’re out on an adventure sometimes your safety can be in the hands of your teammates and you want to know that they have put in the time to be competent, should you need them. With Kati & Erika by my side, I felt fully confident in our crew. With an all-woman team, we all knew and understood just how far we could push ourselves. Adding type 1 diabetes into the mix and we were unstoppable! All of us understood what we were going through when we saw blood glucose spikes during or after an eight-hour paddle or when any of us endured hypoglycaemia that would not let up. Without saying a word, we knew each other’s pains and triumphs. We also encouraged each other, pushed each other and held each other’s packs when someone needed a juice break. Our trio went to the limit and beyond.
34 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 DIABETES IN SOCIETY Type 1 diabetes and pregnancy Ginger Vieira
It wasn’t very long ago when a young girl’s diabetes diagnosis would come with the doctor warning her parents that she would never be able to experience pregnancy and give birth to her own children. In fact, if you have the unfortunate luck of being diagnosed by the wrong medical team, they might still be telling parents and young women that pregnancy with type 1 diabetes (T1D) is out of the question.
Today, it’s very possible for a woman with T1D to pursue a healthy and safe pregnancy. However, women living with T1D need to understand that while this journey doesn’t come without challenges, it’s perfectly natural if the idea of managing diabetes during pregnancy seems daunting. Managing blood glucose with insulin therapy and carbohydrates is complicated on any given day, and it absolutely becomes much more complicated with pregnancy.
With the right support, the correct information and knowledge, a woman with T1D can anticipate how insulin needs and blood glucose will be impacted by the journey of pregnancy. Giving birth is a reasonable pursuit for any woman, and that includes women with T1D.
In 2017, I wrote Pregnancy with Type 1 Diabetes. Simply put, the book was created to provide women with the most important information in order to manage diabetes well during pregnancy. The first mmol/L) or less half of the book is a detailed, in-depth guide to T1D • 1 hour after eating: 130 mg/dL (7.2 mmol/L) to 140 management prior to pregnancy, and the second half mg/dL (7.8 mmol/L) or less of the book guides the reader through each month of • 2 hours after eating or 120 mg/dL (6.7 mmol/L) or pregnancy, delivery, postpartum and breastfeeding. less
Why is pregnancy with type 1 diabetes complicated? These are very general guidelines: most doctors will work The hardest part about managing blood glucose in that with their patients to individualize targets. However, much tighter range during pregnancy is that insulin needs variation in insulin needs will occur. For example, in the will be constantly changing, in part, because of hormones first trimester, insulin requirements will actually decrease which play a big role in glucose fluctuations. Pregnancy and it can be normal to battle constant low blood sugars for any woman, living with diabetes or not, is full of or hypoglycaemia until doses are adjusted. As the second several different types of hormones that increase gradually trimester gets going insulin doses will creep up and many throughout pregnancy. The following targets for blood women will be shocked at how many more insulin units are glucose from the American Diabetes Association give an required to cover something as basic for the carbohydrates idea of the tight control that is required for most pregnant in an apple. Soon though, as everything starts winding women living with diabetes: down and with a delivery date approaching, insulin doses start to decrease again. • Before meals, at bedtime, and overnight: 90 mg/dL(5
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diagnosed with T1D, all doctors will quickly reassure her and her parents that she can absolutely pursue pregnancy.
Ginger Vieira has lived with type 1 diabetes and celiac disease since 1999, and fibromyalgia since 2014. She is the author of Pregnancy with Type 1 Diabetes, Dealing with Diabetes Burnout, Emotional Eating with Diabetes and Your Diabetes Science Experiment. Ginger is a freelance writer and editor at DiabetesDaily.com, with a B.S. in Professional Writing.
1.Standards of Medical Care in Diabetes—2016. Diabetes Care 2016; 39: S94–S98.
Managing type 1 diabetes with pregnancy can be a very complicated journey, but it can be done. Many women are truly shocked by their ability to manage daily blood glucose tighter than they’ve ever managed them before and most people agree that having a healthy baby is the ultimate motivation. It’s not uncommon for women to achieve HbA1c levels that were previously thought to be out of reach.
Once upon a time, I thought pregnancy and T1D were two things I would never want to mix. I told myself that putting the physical and mental stress of pregnancy on my body wasn’t healthy, and I was sure it wasn’t healthy for a baby either. Fortunately, I read stories and saw photos and heard the news of so many other women with type 1 diabetes successfully giving birth to their very own biological children. They did it. I realized I could do it, too. Type 1 diabetes may prevent people living with the condition from producing insulin, but it doesn’t have to stop us from producing a gorgeous, healthy baby boy or girl. Someday, whenever a young girl or woman is
36 Diabetes Voice Online Volume 64 - Issue 3 - October 2017 OUR RIGHT TO A HEALTHY FUTURE
1 in 7 births is affected by gestational diabetes. Protect the health of mother and child by improving access to screening, care and education. ACT TODAY TO CHANGE TOMORROW www.worlddiabetesday.org IDF DIABETES ATLAS 8th EDITION
Coming soon 14 November 2017 World Diabetes Day
www.diabetesatlas.org